BONE GRAFT INFORMED CONSENT

1 bone GRAFT INFORMED CONSENT I _____, understand that when a tooth is extracted, the underlying bone tends to atrophy (shrink). bone grafting is a method to reduce or offset this bone atrophy after extraction(s), or to supplement bone around an implant, in a large sinus cavity, or to treat pocketing around tooth. Donor Human (Allograft) Pre-packaged cadaver bone particles-very effective and reasonable cost. Please read carefully and ask your surgeon if you have questions regarding any of the following: 1). I have been INFORMED , and I understand the purpose, of the bone GRAFT procedure.

2 2). I understand that there may be risks and complications of any procedure including swelling, bruising, pain, bleeding, infection, altered sensation (usually numbness at the donor site), allergic reaction or other adverse reactions to medications or materials used during or after the procedure. 3). I understand that there is no method to predict accurately the gum and bone healing capabilities in each patient following the placement of a bone GRAFT ; and that bone in its healing process remodels and there is no method to predict the final volume of bone , thus additional grafting may be necessary.

3 4). It has been explained to me that, in rare instances, bone grafts fail and must be removed. Lack of adequate bone growth into the bone GRAFT replacement material could result in failure. No assurances or guarantees as to the outcome of the results of treatment or surgery can be made. I am aware that should the bone GRAFT surgery fail, it may require further corrective surgery or the removal of the bone GRAFT with possible corrective surgery associated with the removal. Should the bone GRAFT fail, I understand that alternative non- surgical prosthetic measures may have to be considered.

4 5). I understand that smoking or high blood sugar (diabetes) may affect gum healing and may limit the success of the bone GRAFT . I agree to follow my doctor s home care instructions. I agree to report to my doctor for regular examinations as instructed. 6). To my knowledge, I have given an accurate report of my health history. I have also reported any unusual reaction to drugs, anesthetics, food, insect bites, pollen or dust, any blood or body diseases, gum or skin reactions, abnormal bleeding, or any other conditions related to my health. 7). I request and authorize medical/dental services for me, including bone grafts and other surgery.

5 I fully understand that during and following the contemplated procedure, surgery, or treatment, conditions may become apparent which warrant in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve of modifications in design, materials, or care, if it is felt this is for my best interest, including the decision not to proceed with the bone GRAFT . I have reviewed the above information, and have had the opportunity to have any questions/concerns addressed. Based on the information presented by my doctor(s) regarding my diagnosis, the proposed treatment, the treatment alternatives, and the associated risks and complications of such treatment, I request that you perform the planned surgical treatment.

6 Patient/Parent Signature_____Date_____Witness_____ Doctor Signature_____Date_____ - Page 1 of 4 - ImplantVision Communications LLC CONSENT FORM: AUGMENTATION GRAFTING OF THE MAXILLARY SINUS Part 1 - Patient & Doctor Information Patient Name: _____ Doctor Name: _____ In order for me to make an INFORMED decision about undergoing a procedure, I should have certain information about the proposed procedure, the associated risks, the alternatives and the consequences of not having it. The doctor has provided me with this information to my satisfaction. The following is a summary of this information.

7 This form is meant to provide me with the information I need to make a good decision; it is not meant to alarm me. Part 2 - Details of CONSENT Condition My doctor has explained the nature of my condition to me: Not enough bone to place a dental implant securely. Procedure Augmentation grafting of the maxillary sinus My physician has proposed the following procedure to treat or diagnose my condition: Augmentation grafting of the maxillary sinus This means: Grafting of the maxillary sinus: implant a bone substitute material, freeze dried demineralized bone and/or hydroxyapatite into the floor of the sinus.

8 The doctor will open the gum tissue, expose the bone , make a small opening in the bone , insert GRAFT material in the maxillary sinus, and stitch the gum tissue closed. Healing usually takes 3 to 6 months, and dentures usually cannot be worn during the first few weeks. I should not smoke, drink heavily, use any drugs not prescribed by my doctor, should not blow my nose for at least 2 weeks and not heavily blow my nose for another 2 weeks. 1. After a careful oral examination and study of my dental condition, the doctor has advised me that for future implant placement in the posterior maxillary region I need to have placement of bone in the area of my maxillary sinus.

9 This bone when mature will be able to support dental implants. I hereby authorize the doctor and his authorized associates and assistants to treat my condition. 2. The procedure I choose to treat this condition is understood by me to be bone grafting into the maxillary sinus region. This bone GRAFT could include materials of human, animal, plant or synthetic origin. I understand that the purpose of this procedure is to augment the volume of bone in my maxillary sinus(es) in order to provide enough support for the placement of dental implants in the future. 3. I understand that this is nonetheless an elective procedure, that such procedures are performed to improve function and that an alternative option, although less desirable, is to not undergo surgery and do nothing.

10 I have also been advised that other alternative treatments to placement of dental implants include, but are not limited to, a bridge, a partial denture, full denture, or other options. I understand and choose to undergo maxillary sinus augmentation for the placement of root form implants into the maxillary sinus region in the future. 4. I understand that my gum tissue will surgically be opened to expose the bone . I understand that a small opening will be done in the bone to be able to place the GRAFT material in the maxillary sinus. I understand that the gum tissue will then be stitched closed to permit healing for a period of 3 to 6 months.